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NPs and PAs who bill Medicaid as independent practitioners are more likely to bill for a dermatology visit than for any other office-based service -- so much so that in 2012, 55% of their Medicaid billings were for derm codes, to which dermatologists claim scope of practice violations.

Of the almost 5 million procedures NPs and PAs billed to Medicaid in 2012, the most common involved simple skin biopsies and excision of lesions, wrote of TriHealth Good Samaritan Hospital in Cincinnati, and , a volunteer associate professor at the University of Cincinnati, . They noted that 30% of those procedures were done by NPs and 70% by PAs.

Based on those numbers, the authors concluded that NPs and PAs have been operating outside their original scope of practice in primary care as defined by the Balanced Budget Act of 1997. To remedy this Ratnarathorn and Coldiron want more action from Congress, and this time they want teeth in the bill.

"The [study] clearly illustrates the contributions of PAs and NPs to improving access to care in the United States by [performing] 4,780,651 [procedures]. The authors state that the office visits were done without 'supervision' of a physician, but are unable to provide supporting evidence that this lack of 'supervision' impacted the quality of patient care," , an internal and family medicine clinician in Fredrick, Md., told MedPage Today in an email.

"Unfortunately, the article also lacks comparable data on the number of outpatient procedures performed by physicians, or malpractice data for both physicians and PAs/NPs," Smolko added.

Ratnarathorn and Coldiron included only the most common procedural codes, imposing a minimum of 5,000 as the cutoff, and only those reimbursed at 100%, indicating clinician independence.

, H. Ray Jalian, MD, of the University of California, Los Angeles, and Mathew M. Avram, MD, JD, of Massachusetts General Hospital, pointed out that roughly 40% of liability actions involving laser-induced injury involved services performed by nonphysicians, which they cite as a compelling argument for the value of medical school and dermatology residency training, assets that neither NPs nor PAs can claim.

However, that 40% figure comes from the ), in which they identify only 174 cases of injury over the course of 27 years (1985-2012), the most frequent of which involved laser hair removal in plastic surgery practices. And only 51% of the 120 cases that went to court ruled in favor of the plaintiff.

Moreover that same analysis failed to distinguish between NPs and PAs, and other nonphysician staff who could have been operating laser hair removal equipment.

Scope of Practice

responded to the Ratnarathorn and Coldiron study with a statement that firmly straddled the fence: they support the role of physicians as team-leaders and supervisors of nonphysicians, but they also were careful not to couch that support in language aimed at not offending NPs and PAs.

"The American Academy of Dermatology supports a dermatologist-led care team. We know that many dermatologists employ and appropriately supervise nurse practitioners and physician assistants as part of their integrated team to help provide care for an expanding number of patients, and we support this practice," said president elect of the Academy, Mark Lebwohl, MD.

So how should scope of practice play out in the world of office derm, much of which is provided by primary care practices?

Ratnarathorn and Coldiron give a side-by-side comparison of dermatologist expertise to NP and PA lack of experience outside of the primary care setting, but they make no mention of family physicians.

"In my practice, I routinely remove skin tags, treat warts and do cryotherapy on various lesions. These were a part of my residency training in Family Medicine," Michael Gutierrez, MD, a family physician in private practice in Austin, Texas, told MedPage Today. Family Medicine residency training includes 4-6 months in a surgery rotation, where biopsy and excision skills are acquired, according to Gutierrez.

Furthermore, the researchers pinpoint lack of dermatologic-specific training for NPs and PAs, claiming dermatologists undergo 10,000 hours of clinical training compared with NP or PA exposure of 500-900 hours, but the citation is from an American Academy of Family Physicians ," which does not mention PA training hours at all, and does not reference NP or PA training standards as sources for the data, or any peer-reviewed studies.

"In addition to the lack of evidence of different patient outcomes in encounters provided by PAs versus physicians, the authors incorrectly claim PAs have a mere 500-900 hours of clinical training. PAs have over 2,000 clinical training hours while in school (not including the thousands of hours prior to applying to PA school), including rotations in Family Medicine, Internal Medicine, Surgery, Gynecology and Obstetrics, Pediatrics, Psychiatry, etc," Smolko said.

"PAs are trained in the same medical model as physicians, are board certified by exams every 10 years, accrue a minimum of 100 hours of CME every 2 years, and complete quality improvement projects similar to their physician colleagues," she added.

The data analyzed by Ratnarathorn and Coldiron did not include background information about the NPs and PAs who billed for dermatology procedures in 2012 to determine if those NPs and PAs had trained in a dermatology clinic prior to independent practice.

Access to Care

"[The study] also fails to recognize the impact of patient access to a primary care provider (like PA/NP) who is skilled in performing biopsies, incision and drainage, complex closures, etc.," Smolko said.

A 2014 Merritt Hawkins survey, Smolko said, found typical wait times to see a dermatologist were .

"Patients expect excellent care at the time when they need it most, not waiting months (or almost one year) to be seen by a specialist. The procedures highlighted in the article are within the scope of care of all primary care providers including PAs, NPs and physicians," she said.

And in rural settings, where patients do not have access to a board certified dermatologist, an NP or PA, who may have years of training and experience, might be the only option for care.

"About 5.8% of dermatologists are in rural areas compared to 9% of physicians and 20% of family physicians," , a professor in rural family medicine at the School of Osteopathic Medicine in Arizona, told MedPage Today in an email.

Bowman referenced the 'Active physicians only' section of the American Medical Association's 2013 Masterfile, and also found that in the 2,620 counties with the lowest clinician concentrations, 40% of the U.S. population has access to 36% of family physicians, 20% of physicians, and only 16% of dermatologists.

Call for Restrictions

Ratnarathorn and Coldiron want to see a single state medical and nursing board to oversee NPs and PAs in independent practice, even though physicians are licensed on a state-by-state basis. NPs and PAs can practice independently in 22 states.

In conclusion section, the study authors cite results from a 2008 AMA survey, which found that almost 40% of the public mistakenly believed a doctor of nursing was a medical doctor, and they go on to call for Medicaid to restrict independent Medicare payment of PAs and NPs to primary care.

"Perhaps a more accurate conclusion for the article might be that more that 4 million patients were treated by PAs and NPs, with equivalent quality and safety, without waiting months to be seen by a dermatologist at 85% of the cost to Medicare," Smolko said.

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